Provider Demographics
NPI:1639168479
Name:FOSTER, MARK JAMES (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:FOSTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5919
Mailing Address - Country:US
Mailing Address - Phone:970-247-8382
Mailing Address - Fax:970-259-4403
Practice Address - Street 1:1942 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3039
Practice Address - Country:US
Practice Address - Phone:970-516-5500
Practice Address - Fax:970-516-2500
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ750077Medicaid
CO48529222Medicaid
NM43856560Medicaid
P77092Medicare UPIN
NM43856560Medicaid
CO48529222Medicaid
AZ750077Medicaid